Why universal health coverage needs better measurements

The issue of universal health coverage (UHC) is a hot topic these days. The WHO director general Margaret Chan calls it: “the single most powerful concept that public health has to offer”. A report from the UN-established High Level Panel of Eminent Persons says it is the best hope for achieving better health outcomes in future.

But what does universal health coverage actually mean? The WHO defines it as a system which ensures that all people can access the health services they need and in sufficient quality for them to be effective, while ensuring that the use of services does not expose the user to financial hardship.

This definition embodies three related objectives:

equity in access to health services - those who need the services should get them, not just those who can pay for them;

that the quality of health services is good enough to improve the health of those receiving them;

financial-risk protection - ensuring that the cost of using care does not put people at risk of financial hardship.

That’s a lot of ground to cover especially in Asia and the Pacific, where equity in access to health services is low, the quality of health services varies, and out-of pocket expenditures are the highest in the world.

The region, though, is looking to confront these challenges. ASEAN governments, for example stated in 2012 that they want to provide UHC for the more than 2 billion people in their sub- region.

So is their one common model for providing UHC that all countries in the region look to follow?

The answer is no. Countries have neither simply adopted a National Health Service model, which relies on general taxes, one national risk pool, and publicly provided services available to all, nor a social health insurance model which relies on household premiums and payroll taxes, many risk pools, and services purchased largely from private providers available to those who have enrolled.

Instead many countries have created hybrid systems to meet their own specific needs. In short, there is no one size fits all model for successfully delivering UHC.

A paper published in Lancet last year suggests looking at three dimensions when assessing progress towards UHC. They are:

Who is covered?

What services are covered?

What proportion of cost is covered?

The paper also suggests that common, comparable indicators of progress are needed to allow countries carrying out reforms to assess outcomes, and to make midcourse corrections in policy and implementation. Such a set of indicators would also allow development partners to design effective country specific investments in UHC.

At the moment progress towards UHC is driven by policy decisions which prioritize one dimension over the other and are affected by how successful a country has been in revenue generation and pooling and delivery ― which depends on many factors.

Indicators like coverage for example are often meaningless when we consider the weak Civil Registration and Vital Statistics systems and the low proportion of costs covered. Ultimately, this can send wrong signals about progress made towards UHC and create proclamatory UHC systems without much development impact.

For ADB, getting involved in developing common indicators to assess progress towards UHC, and assisting developing member countries to design and implement cost-effective hybrid systems is a challenging but rewarding task.